by Proactive LTC Consulting | Dec 10, 2025 | Care Planning, Clinical, Coding, Dietary, Documentation, MDS, Medicaid, Medicare, Nursing, PDPM, Physicians
Q: Can I code Malnutrition (Section I5600) on the MDS based on a dietary assessment that identifies the resident as at risk for malnutrition? A: No. Dietitian assessments alone do not provide sufficient documentation for coding of this item on the MDS. ...
by Proactive LTC Consulting | Dec 3, 2025 | Compliance, Documentation, MDS, Nursing, Quality
Q: What types of services are included in the coding of Respiratory Therapy on the MDS? Can this be done by CMTs? What must be included in the documentation to code Respiratory Therapy? A: Appendix A of the RAI manual defines Respiratory Therapy as “Services...
by Proactive LTC Consulting | Nov 26, 2025 | Clinical, MDS, Nursing, Quality, Quality Measure, RAI Manual, Weight Loss
Q: Our facility has been flagged on the Weight Loss Quality Measure (QM. Upon reviewing the clinical records of residents identified with unplanned weight loss, we found several cases where a previous monthly weight documented on the prior MDS was likely inaccurate....
by Proactive LTC Consulting | Nov 19, 2025 | Documentation, MDS, Medicaid, Nursing, PDPM, Quality, Regulatory, Reimbursement
Medicaid Case Mix Index Under PDPM: What LTC Facilities Need to Know As of October 1, 2025, the nationwide transition away from RUG-based Medicaid systems marks a major shift for long-term care. With more states moving to PDPM-based methodologies—and many...
by Proactive LTC Consulting | Nov 12, 2025 | CAA, Care Planning, Compliance, MDS, Nursing, Person Centered Care, Quality
Q: How are residents and their families involved in the CAA process? A: The Care Area Assessment (CAA) process is the foundation for developing each residents individualized care plan. The information gathered during CAAs helps the interdisciplinary team...
by Proactive LTC Consulting | Oct 29, 2025 | 5-Star, MDS, Nursing, Pressure Ulcers, Quality, Quality Measure
Q: I have a resident with an in-house acquired Stage 2 pressure injury. He went out to the hospital for three days and upon return, it was documented as Stage 4. How should this be coded on the MDS? A: The RAI User’s Manual (v1.18.11, effective Oct. 1, 2025)...
